P - 835726 �8�- 710 �
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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: New
Industrial Farm Remod
Htg. Equi . Water Htr. Load Mgmt. Other:
8ang Elec. Heat Temp. Service
�over y this request. Enter remarks in this space and on the
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of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Siz Fee # Circuits/Feeders
Mobile Home Park Stall to 0 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimmin Pool
Fee
9 I here cerfi ihat I in the ei 'cal insiallation described herein on 1he dafes stafed
Irrigation B ' t`. r-- - RougM�
Speciallnspection � �— �� �
Find
Investigative Fee "
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in 11iis box.
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* 0 6 7 8 7 1 0 S* �
PLEASE PRINT OR TYPE
Requesf Dofe RougFFin inspeclion required$ es ❑ No Inspecfion Other Than RougMn: ❑ Ready Now �II Call
1 l�' (You musf call ihe inspeclor when ready) Date Ready:
I, licensed conhacror ❑ owner hereby request inspection of the above elecfrical work at:
Signature
o. No.
(Company Name)
���
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ticense
Phone No.
Masfer lic. No.
Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY